PHSO investigation: Kent and Medway Mental Health NHS Trust (30 April 2026)

Summary

A knife attack might have been prevented if the perpetrator had received better mental health care, an investigation by England’s Parliamentary and Health Service Ombudsman (PHSO) has found. 

In November 2020, a 31-year-old man stabbed a man in his thirties, just one month after being discharged from the care of Kent and Medway NHS and Social Care Partnership Trust, now called Kent and Medway Mental Health NHS Trust. He was arrested and later detained under the Mental Health Act. After the attack he was diagnosed with schizophrenia.  

The Parliamentary and Health Service Ombudsman (PHSO) found a series of failings by the Trust in the 12 months leading up to the stabbing. These included poor care planning and discharging the patient without reviewing his risk level. 

The Ombudsman concluded that these failings might have contributed to the man’s mental health decline. Had he received safe and appropriate care, the stabbing might not have occurred. 

PHSO has repeatedly raised concerns about systemic failings in mental health services. In 2024, the Ombudsman published a report highlighting failures in transferring people with mental health conditions out of services. The report found failures in planning, communication, and continuity of care, and called for services to be more holistic, joined up, and person-centred.